The new CVS opioid to OTC thing

[WVUPharm2007]

So what's everyone's opinion on this? This is sure to piss the everloving hell out of dentists everywhere. I feel like we are overstepping. Though I can see where CVS is coming from considering the legal atmosphere right now.

For non CVS workers, they are making pharmacists intervene on ALL opioid scripts from dentists. If we get an Rx from a dentist for an opioid, we have to offer to give the patient free Tylenol and Advil, put the Rx on hold, and tell the patient that opioid therapy as first line therapy is against ADA guidelines. And if the Rx is on hold for more than 7 days, you have to call the dentist to confirm the patient still needs it.

I anticipate a **** show.

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[MilknCheerios]

I know a few dentists and what they've told me is that they often write scripts for opioid pain medication simply because their patients expect it. New dentists will advise tylenol and ibuprofen. Then, as they get experienced and more patients complaint about pain, they gradually offer stronger pain meds since it's within their power. Does the patient need it? probably not, but once you set a precedent, it's harder to undo it.

From a pharmacy perspective, it sounds nice on paper but the method is flawed. If corporate was upfront by sending a letter to the dentist office notifying them of the change and why, that would relieve some of the work the pharmacist has to do and not ruin any dentist-pharmacist relationship that exists. I advocate pharmacists to double check when opioids are really necessary but singling out all dentist RXs requires a gentler touch, not more phone calls.

 

[ranger99rx]

I do counsel patients to use ibu/Tylenol first before opioid. Some took my advice and didn't even use opioid at all. Some told me ibuprofen actually worked better. My son had 4 wisdom teeth extracted and he only took ibu 200mg a couple times. Didn't even filled the Norco but then some people are different. To put rx on hold is a bit extreme to me. I would counsel and offer free ibu/Tylenol but still give them option to fill opioid if they want to. If patient insisting of getting opioid, you won't fill it? Give rx back? Call dentist? Best way to deal with this is at drop off, so you don't have to deal with angry customers at pick up. Same with Walmart 7 days first fill and/or >50 mme, just turn away unless they ok with 7 days and to have md change direction for </= 50 mme.

 

[RxPreceptor]

Seems a bit harsh to single out dentists as they generally take enough **** as it stands. It is what it is...I barely have any dentists write for unusually large quantities (usually max 20 tablets); 7 day limit on first fills already in effect where I'm at with border states even harsher (5 day limits).

 

[radio frequency]

Honestly, most dentists don’t need to be writing for opioids. They usually are given due to patient demands. I once asked my dentist about this as I never see any controlled Rxs from her office. She said she just doesn’t write for them, period. If you can practice without them as a general practice dentist, I think it says something about their necessity.

I agree with the post above that this is a flawed method for dealing with the problem though. Being upfront about it or getting legislation passed in states about these scripts may be more effective.

 

[Sine Cura]

Opioid therapy is against ADA guidelines?

This is all I found so far

Current Policies

All major policies adopted by the American Dental Association House of Delegates from 1954 through 2020 (still in effect in 2021)...

www.ada.org

Policy on Opioid Prescribing (2018)

Resolved, that the ADA supports mandatory continuing education (CE) in prescribing opioids and other controlled substances, with an emphasis on preventing drug overdoses, chemical dependency, and diversion. Any such mandatory CE requirements should:

1. Provide for continuing education credit that will be acceptable for both DEA registration and state dental board requirements,
2. Provide for coursework tailored to the specific needs of dentists and dental practice,
3. Include a phase-in period to allow affected dentists a reasonable period of time to reach compliance,

and be it further


Resolved, that the ADA supports statutory limits on opioid dosage and duration of no more than seven days for the treatment of acute pain, consistent with Centers for Disease Control and Prevention (CDC) evidence-based guidelines, and be it further


Resolved, that the ADA supports improving the quality, integrity, and interoperability of state prescription drug monitoring programs.


American Dental Association
October 2018

Benefits and harms associated with analgesic medications used in the management of acute dental pain
This preceding is a systematic review where it was concluded "that relief of postoperative pain in dental practice with the use of nonsteroidal anti-inflammatory drugs, with or without acetaminophen, is equal or superior to that provided by opioid-containing medications."

 

[JustFillIt]

So what's everyone's opinion on this? This is sure to piss the everloving hell out of dentists everywhere. I feel like we are overstepping. Though I can see where CVS is coming from considering the legal atmosphere right now.

For non CVS workers, they are making pharmacists intervene on ALL opioid scripts from dentists. If we get an Rx from a dentist for an opioid, we have to offer to give the patient free Tylenol and Advil, put the Rx on hold, and tell the patient that opioid therapy is against ADA guidelines. And if the Rx is on hold for more than 7 days, you have to call the dentist to confirm the patient still needs it.

I anticipate a **** show.

Haha just one more thing...

 

[BidingMyTime]

There are probably a few dentists out there who give opioids to everyone, but I think most dentists are pretty conservative and only give opioids when they have done alot of work, or if the person can't take NSAIDS. But I guess it's easier to cut off all the dentists, rather than just deal with the few dentists who are causing the problem. I highly doubt that even a significant minority of opioid addicts, got their start by a dentist writing them an RX.

 

[Rouelle]

Folks at store level will find a way to pencil-whip a bypass around this.

 

[wagrxm2000]

There is plenty of information showing Advil to be just as effective for pain as opioids. I have no issue with this.

 

[Dr Wario]

Well we had a famous dentist that gave every patient #15 oxy/apap 10/325, we sometimes would precount the pills because we would get 20+ of these scripts a day. Later found out he was the subject of an FBI sting for trading the pills or money for sex with underage girls. This was quite a while ago before the opioid crisis came to light.

But in seriousness, I have always said that the only real way to help this crisis was to prevent people from taking this stuff in the first place, once someone is already addicted you have an impossible battle.

 

[CardinalGirl210]

I know a few dentists and what they've told me is that they often write scripts for opioid pain medication simply because their patients expect it. New dentists will advise tylenol and ibuprofen. Then, as they get experienced and more patients complaint about pain, they gradually offer stronger pain meds since it's within their power. Does the patient need it? probably not, but once you set a precedent, it's harder to undo it.

From a pharmacy perspective, it sounds nice on paper but the method is flawed. If corporate was upfront by sending a letter to the dentist office notifying them of the change and why, that would relieve some of the work the pharmacist has to do and not ruin any dentist-pharmacist relationship that exists. I advocate pharmacists to double check when opioids are really necessary but singling out all dentist RXs requires a gentler touch, not more phone calls.

Sounds like those dentists need to grow a pair

 

[BenJammin]

CVS asking their pharmacists to practice medicine without a license?

 

[owlegrad]

CVS asking their pharmacists to practice medicine without a license?

Which part is practicing medicine? Giving out an OTC? Or using guidelines to limit the dispensing of certain scripts?

 

[owlegrad]

There are probably a few dentists out there who give opioids to everyone, but I think most dentists are pretty conservative and only give opioids when they have done alot of work, or if the person can't take NSAIDS. But I guess it's easier to cut off all the dentists, rather than just deal with the few dentists who are causing the problem. I highly doubt that even a significant minority of opioid addicts, got their start by a dentist writing them an RX.

Agreed. I would be very curious to know how many people ever got hooked on opioids due to a dental script. My bet is very few if any.

 

[RxPreceptor]

CVS asking their pharmacists to practice medicine without a license?

Might be referring to the offering of free drugs as a compromise for flat out refuse to fill an opioid from dentists. Seems like overstepping boundaries and taking away any authority/autonomy of dentists' judgment but at the same time is an attempt to assure all possible OTC options have been exhausted, doses considered.

I personally feel like there are enough opioid prescribing restriction (where I am at at least, first fill day supply limits AND first fill RX expiration date - expires 30 days after date of issue) but that more uniform/FEDERAL mandated restrictions would probably be a better way to go about the issue rather than targeting specific prescriber types. Other factors being the slew of insurance restrictions for first fills being more common; still need to cut down on cashed out opioid Rxs

 

[RxPreceptor]

Agreed. I would be very curious to know how many people ever got hooked on opioids due to a dental script. My bet is very few if any.

From what I've gathered, those parts of the country where 5 day and 7 day first fill restrictions are in place....those days were chosen based on the statistics of consecutive days supply of opioid usage to deter development of physiological tolerance

 

[JustFillIt]

Folks at store level will find a way to pencil-whip a bypass around this.

This is what I would have done. Just have a technician notify them and have them sign a waiver... or something like that.

All the while have it bottled, labeled, and ready to go for when they tell you your an idiot.

 

[radio frequency]

Agreed. I would be very curious to know how many people ever got hooked on opioids due to a dental script. My bet is very few if any.

In children it is actually a concern because it’s often their first exposure to opioids and legitimate use in this population is associated with future misuse. High schoolers often get these prescriptions for wisdom tooth removal.

“Legitimate opioid use before high school graduation is independently associated with a 33% increase in the risk of future opioid misuse after high school. This association is concentrated among individuals who have little to no history of drug use and, as well, strong disapproval of illegal drug use at baseline.”

Prescription Opioids in Adolescence and Future Opioid Misuse

BACKGROUND AND OBJECTIVE:. Legitimate opioid use is associated with an increased risk of long-term opioid use and possibly misuse in adults. The objective of this study was to estimate the risk of future opioid misuse among adolescents who have not yet graduated from high school.METHODS...

pediatrics.aappublications.org

End first exposure: Dentistry's biggest opportunity in the opioid crisis

Sometimes you read a research article and it hits you between the eyes like a sledgehammer. So it was when I read “Prescription Opioids in Adolescence and Future Opioid Misuse” published in the journal Pediatrics in 2015. It made me really reconsider the impact dentists can have on ameliorating...

www.cda.org

I’ve also seen well meaning dentists prescribe drug seekers known to pharmacies narcotics for complaints of mouth pain after procedures where it may not always be warranted. They often are sympathetic and don’t use the PDMP to check for misuse.

 

[ifillrxs]

It seems like every regulatory agency wants pharmacists to be more involved in the opioid crisis. I feel prescribers fall into a routine they become comfortable with. They don't necessarily follow guidelines and there is no one to correct them because they are still following the law.

If a patient comes to me to fill their prescription, I'm now part of the equation. I share responsibility. I'm not used to this current level of involvement but it makes sense. Thinking back, how many times have you helped someone who presented a family member's amox, ibu, (opioid rx of choice), and Peridex rxs. The family member drags the patient into the pharmacy waiting room instead of taking them home and making them comfortable. They insist on waiting because he/she needs it NOW. Speaking from my personal experience, my face is numb for hours. Maybe the dental provider needs a reminder on the current guidelines. This action would probably force the issue as patients complain to their dental provider.

I like the idea of it, but to do it while understaffed, filling hundreds of other prescriptions and making dozens of daily patient phone calls , not so much.

 

[RxPreceptor]

In children it is actually a concern because it’s often their first exposure to opioids and legitimate use in this population is associated with future misuse. High schoolers often get these prescriptions for wisdom tooth removal.

“Legitimate opioid use before high school graduation is independently associated with a 33% increase in the risk of future opioid misuse after high school. This association is concentrated among individuals who have little to no history of drug use and, as well, strong disapproval of illegal drug use at baseline.”

Prescription Opioids in Adolescence and Future Opioid Misuse

BACKGROUND AND OBJECTIVE:. Legitimate opioid use is associated with an increased risk of long-term opioid use and possibly misuse in adults. The objective of this study was to estimate the risk of future opioid misuse among adolescents who have not yet graduated from high school.METHODS...

pediatrics.aappublications.org

End first exposure: Dentistry's biggest opportunity in the opioid crisis

Sometimes you read a research article and it hits you between the eyes like a sledgehammer. So it was when I read “Prescription Opioids in Adolescence and Future Opioid Misuse” published in the journal Pediatrics in 2015. It made me really reconsider the impact dentists can have on ameliorating...

www.cda.org

I’ve also seen well meaning dentists prescribe drug seekers known to pharmacies narcotics for complaints of mouth pain after procedures where it may not always be warranted. They often are sympathetic and don’t use the PDMP to check for misuse.

So true...Long time ago when I was in a affluent suburb (killer low land values) filled with spoiled brat kids 16 years old given their own car(s), cell phones, etc. this was a huge problem in my area; suboxone was a fast mover if that paints the picture better. Always felt awkward as F to see the look on the parent's face (shame, disappointment, rage) when these spoiled entitled little brats would partake in pharma-parties (pilfer, collect various opioids from wisdom teeth extractions and parents' medicine cabinet)

 

[aznkukuboi]

When did this come out? I'm out of the county and didn't hear about this at all.

 

[mentos]

When I got my wisdom teeth out in my early 20s (before I know anything about pharmacy) I was given Motrin, Augmentin, and Vicodin. Neither the oral surgeon nor the pharmacy counseled me about what I was taking, I just thought I had to take everything. I passed out after taking a Vicodin and then threw the rest away. I was never in pain, I don't think I even finished the Motrin.

When I worked retail, half the patients from the dentist or ER didn't know they were prescribed an opioid just like myself when I was young.

They should be targeting ER docs IMO cause they're the ones that give them out like candy.

 

[BenJammin]

Which part is practicing medicine? Giving out an OTC? Or using guidelines to limit the dispensing of certain scripts?

WVU said that they are instructed to put the prescription on hold and then offer Tylenol/Motrin according to guidelines. Prediabetes guidelines also say that weight loss and exercise are first line treatment. Would you be fine with CVS putting brand new metformin prescriptions on hold and instructing the patient on an exercise regimen and diet plan? I don't see how that's any different from the dentist/opioid approach.

 

[Splenda88]

WVU said that they are instructed to put the prescription on hold and then offer Tylenol/Motrin according to guidelines. Prediabetes guidelines also say that weight loss and exercise are first line treatment. Would you be fine with CVS putting brand new metformin prescriptions on hold and instructing the patient on an exercise regimen and diet plan? I don't see how that's any different from the dentist/opioid approach.

It would nice. But we ALWAYS try these approaches before prescribing. Americans want easy and quick fix (although taking metformin is not a quick fix). It might be more effective to use laws to deal with the opioid crisis than having pharmacists to deal with angry patients/prescribers... Based on my experience as resident, I think most physicians are very careful with opioid prescribing habit.

 

[WVUPharm2007]

When did this come out? I'm out of the county and didn't hear about this at all.

The training was due 9/27. I'm sure you'll come home to 25 emails about it from your DL.

 

[WVUPharm2007]

WVU said that they are instructed to put the prescription on hold and then offer Tylenol/Motrin according to guidelines. Prediabetes guidelines also say that weight loss and exercise are first line treatment. Would you be fine with CVS putting brand new metformin prescriptions on hold and instructing the patient on an exercise regimen and diet plan? I don't see how that's any different from the dentist/opioid approach.

To clarify, the patient can still tell us to piss off and we will fill the opioids. We are to strongly recommend OTC therapy first.

 

[owlegrad]

WVU said that they are instructed to put the prescription on hold and then offer Tylenol/Motrin according to guidelines. Prediabetes guidelines also say that weight loss and exercise are first line treatment. Would you be fine with CVS putting brand new metformin prescriptions on hold and instructing the patient on an exercise regimen and diet plan? I don't see how that's any different from the dentist/opioid approach.

You see no difference between metformin for pre-diabetes and opioids for dental pain? Ok fair enough.

 

[WVUPharm2007]

You see no difference between metformin for pre-diabetes and opioids for dental pain? Ok fair enough.

I can. One involves DEA scrutiny and emerging lawsuits against anyone involved in narcotics prescribing processes. The other, not as much.

 

[zelman]

I have a million questions. Here’s my top 6-ish:

1. How much free drugs can I get?
2. Is there a methodical screening process to make sure you don’t give NSAIDs to people with ESRD/CKD or APAP to people with liver dysfunction?
3. Or people with allergies?
4. How do you decide which OTCs to give out?
5. Does the policy vary between DDS’ and DMD’s prescriptions?
6. Does it apply to emergency room Rx’s for dental pain?

 

[JustFillIt]

I have a million questions. Here’s my top 6-ish:

1. How much free drugs can I get?
2. Is there a methodical screening process to make sure you don’t give NSAIDs to people with ESRD/CKD or APAP to people with liver dysfunction?
3. Or people with allergies?
4. How do you decide which OTCs to give out?
5. Does the policy vary between DDS’ and DMD’s prescriptions?
6. Does it apply to emergency room Rx’s for dental pain?

Sure - most smart retail pharmacists understand this. So, it won’t be long before the pencil whip process begins.

 

[KunjooSea]

So what's everyone's opinion on this? This is sure to piss the everloving hell out of dentists everywhere. I feel like we are overstepping. Though I can see where CVS is coming from considering the legal atmosphere right now.

For non CVS workers, they are making pharmacists intervene on ALL opioid scripts from dentists. If we get an Rx from a dentist for an opioid, we have to offer to give the patient free Tylenol and Advil, put the Rx on hold, and tell the patient that opioid therapy as first line therapy is against ADA guidelines. And if the Rx is on hold for more than 7 days, you have to call the dentist to confirm the patient still needs it.

I anticipate a **** show.

That is so wrong. What is wrong with people. I would walk out. In fact, it is cruel.

 

[KunjooSea]

That is so wrong. What is wrong with people. I would walk out. In fact, it is cruel.

 

[SoylentGreen]

As a Walmart pharmacist, thank god it's not just us anymore (not that we have this particular policy, I mean getting in the way of opioid prescribing in general).

 

[BenJammin]

You see no difference between metformin for pre-diabetes and opioids for dental pain? Ok fair enough.

From the perspective of a pharmacist refusing to dispense it and practicing medicine without a license? There is no difference.

 

[owlegrad]

From the perspective of a pharmacist refusing to dispense it and practicing medicine without a license? There is no difference.

I don’t think that means what you think that means.

Scrutinizing narcotics? Not practicing medicine. Giving away OTCs? Not practicing medicine.

Also the pharmacist isn’t refusing to dispense, but even if they were, refusing to dispense isn’t practicing medicine.

 

[Lnsean]

damn CVS really doing this? looks like a clusterfk of an explanation you have to do with your patients, but i bet the majority of rphs will just mark whatever needs be on whatever forms corporate has them filling out for this nonsense

 

[Mr. Corporate Pharmacist]

I am all for this. I don't see the big deal when it's the patient's choice. They get free medicine and education about less risky treatment.

CVS is taking on the cost to give away free OTC samples. And the patient can still pick up the original opioid within 7 days.

It just gets deactivated after the 7 days, which seems appropriate to me.

 

[Sine Cura]

In California this policy can be interpreted as "obstructing" a patient in "obtaining a prescription drug or device that has been legally prescribed or ordered for that patient". The permitted conditions to refuse a prescription do not include following some B.S. corporate policy.

Law section

leginfo.legislature.ca.gov

 

[WVUPharm2007]

In California this policy can be interpreted as "obstructing" a patient in "obtaining a prescription drug or device that has been legally prescribed or ordered for that patient". The permitted conditions to refuse a prescription do not include following some B.S. corporate policy.

Law section

leginfo.legislature.ca.gov

Ok, again, you aren't refusing to fill. You are to strongly recommend against using opioids and try OTCs first. If the patient isn't interested, you fill the opioid.

 

[Sine Cura]

Can you give a e-script back? Deactivating Rx... wut?

Have fun explaining it to a board inspector

Aside from the non-zero risk to your license (probably PIC only not staff RPH) I actually "enjoy" corporate B.S. like this (example with Walmart's 2020 "escripts ONRY" for controls) just to see the dumbfounded reactions from customers

 

[lord999]

In California this policy can be interpreted as "obstructing" a patient in "obtaining a prescription drug or device that has been legally prescribed or ordered for that patient". The permitted conditions to refuse a prescription do not include following some B.S. corporate policy.

Law section

leginfo.legislature.ca.gov

No, formulary substitution is permitted, and this would probably be argued as such. And, that doesn't preclude blanket practice policy which can, it just can't be capricious. That said, what a headache for the rank and file pharmacist, why should they have to clean up this prescriber mess and take the free heat? On the other hand, I have a bunch of addicts that I had been forced to dispense to in my head right now, and you know, I really don't mind a draconian policy given my memories of them.

 

[Sine Cura]

CCR 1716 specifically prohibits deviating from the prescription (formulary substitution is not prohibited per se for inpatient orders) with variations permitted pursuant to BPC 4052.5, BPC 4073, BPC 4064.5

"This rx is contrary to ADA recommendations yet we will fill it if you bitch about it" doesn't sound like a defensible blanket policy.

 

[owlegrad]

For the people who think this policy is bad, what role do you think pharmacists should play in preventing addiction to narcotics?

 

[zelman]

For the people who think this policy is bad, what role do you think pharmacists should play in preventing addiction to narcotics?

Accurately filling prescriptions, reporting the prescription data to the state PDMP, and communicating concerns to prescribers. The actual police/DEA should be using the reported data to deal with diversion and the prescribers should be dealing with the drug seeking patients. The fact that I’m responsible for the addiction issues of people that I have never met is baffling to me.

 

[Lnsean]

Accurately filling prescriptions, reporting the prescription data to the state PDMP, and communicating concerns to prescribers. The actual police/DEA should be using the reported data to deal with diversion and the prescribers should be dealing with the drug seeking patients. The fact that I’m responsible for the addiction issues of people that I have never met is baffling to me.

Very well put.

 

[Mr. Corporate Pharmacist]

Accurately filling prescriptions, reporting the prescription data to the state PDMP, and communicating concerns to prescribers. The actual police/DEA should be using the reported data to deal with diversion and the prescribers should be dealing with the drug seeking patients. The fact that I’m responsible for the addiction issues of people that I have never met is baffling to me.

I don't see us as being responsible for addiction issues. Whether or not someone is addicted is not a driving force that changes how I practice pharmacy.

I'm more concerned with:

1) legitimate use
2) prescriber scope of authority
3) patient safety
4) legal and regulatory compliance

Opioid to OTC fits in all those buckets IMO

As long as we aren't breaking any laws while increasing scope of our practice, I think we can do even more for patients in the future.

 

[KidPharmD]

IF (world's largest if) CVS had allocated resources for this extra clinical work (which they certainly won't) this would be great. I see no problem with this as a policy.

There is no medicine being practiced here. The prescription is not changed (OTC's are being dispensed as OTC's not as a replacement for the Rx). No refusal is being made. This isn't obstruction. Our BOP would LOVE this policy.

 

[Sine Cura]

For the people who think this policy is bad, what role do you think pharmacists should play in preventing addiction to narcotics?

Druggies have many resources available like MAT should they avail themselves of them and many illegitimate resources so that they don't waste time going to the dentist for #10 to #21 Norco if they do not care about dying. Also pharmacists do counseling, which sometimes involves the discussion of risks of medications.

Obviously no script is being changed. The "obstruction" part is specific to California where pharmacies and PICs can get cited for untimely refill authorization requests and delayed drug deliveries. CVS's PR stunt is limp-wristed B.S. like W's 2020 e-script ONRY policy.

 

[trailerpark]

Why can’t we focus on the true problem of MDs. Dentists are not the problem. It’s the MD who writes for 120 opioids every month for chronic pain.